Contributed by: Gary Lai
The following is Part II of Gary Lai’s investigation into the link between poverty and health outcomes. Part I is available here.
Economic Inequality and Health Inequality
There is a large array of political tools to advocate for the poor in the framework of The Canada Health Act (1984). For Example, Dennis Raphael, from York University, proposed a series of actions to reduce poverty and health inequality. He cited the Health of Canada’s Children Report, which reported a deep divide between the health of children who are poor and those who are not. Statistics Canada attributes 22% of mortality differences among Canadians to income differentials. In the University of Sussex’s Richard Wilkinson’s book Unhealthy Societies, he writes, “increasing economic inequality decreases social cohesion, increases individual malaise, and produces the conditions by which increased mortality and morbidity occur.” Raphael also mentioned that the Ottawa Charter for Health Promotion included income as a basic prerequisite for health. He wrote that the public, organizations, and the government could respond to a public health issue like this through recognition of the impact of politics, government policy development and implementation, and community involvement on health.
Raphael is not the only scholar advocating a political solution. Deanna Williamson, of the University of Alberta, claimed that the health of individual Canadians in poverty requires a concerted effort to alter the “fundamental structural conditions contributing to poverty.” She suggested more research in this area.
Social Determinants of Health
In 2015, Raphael claimed that Canadian public policy created health inequalities, by endowing different socio-economic groups unevenly with various social determinants of health (SDOH). SDOH are, according to the World Health Organization, “the conditions in which people are born, grow, live, work, and age.” They are a product of the “inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally.”
Feeding hungry people through food banks and community food kitchens does not address poverty in the long term || (Source: Flickr // Mike Nice)
Raphael identified Canada as a liberal welfare state, in which the government “provides fewer economic and social supports for the population, universal benefits are sparse, and state provision of modest benefits is targeted at the least well off.” The distribution of wages and benefits is unequal, and the labour sector is weak. Income, housing (the affordability of which is a determinant of poverty), and food security are distributed unevenly as a result. These unevenly endowed SDOH lead to inequalities in the incidences of health-threatening behaviours and psycho-social stress.
There are alternatives to the liberal welfare state, such as social democratic, conservative, and Latin state models. A social democratic welfare state would favour the goals of poverty reduction, equality, and employment over market-driven values. It is possible to deviate from or replace a welfare state model with another. For example, Canada deviated from the liberal welfare model when it embraced a quasi-socialist Medicare system. So, Raphael suggests research as to whether the public supports the current liberal welfare state, which contributes to health inequality through how socio-economic resources are distributed. Another possible area of research is how influential health-oriented charities view SDOH.
Patricia Collins, of Queen’s University, and her colleagues observed that feeding hungry people through food banks and community food kitchens does not address poverty in the long term. Moreover, municipal-level initiatives give provincial and federal governments less incentive to reduce income insecurity using social programs. There is, therefore, a need to study the costs of delivering provincial and federal social benefits compared to food-based initiatives.
Since the introduction of Bolsa Família, pregnant women visit their doctors more frequently, and more babies receive all their required vaccines by six months || (Source: Flickr // Pan American Health Organization)
An example of a successful program that addresses the root causes of household food insecurity (HFI) is the Bolsa Família (Family Grant) program in Brazil. Organized in its present form by President Lula in 2003, it is the largest conditional cash transfer program in the world. With a $6.8 billion budget, it serves 13 million families – approximately one quarter of all Brazilian households. The cash transfer to low-income citizens is conditional on educational and health requirements, such as prenatal care and vaccinations. Due to the Family Grant, health care utilization has increased. Pregnant women visited their doctors, on average, 1.5 more times since the grant was introduced. Further, the number of babies who had received all required vaccinations at six months increased by 12-15% following the implementation of the program. Another result of the program was a decrease in income inequality. In a study of the program, in a 2013 issue of Lancet, Davide Rasella, of the Universidade Federal da Bahia in Salvador, and his colleagues found that closing the income gap led to an increase in life expectancy. Family Grant has been widely lauded as a success in poverty alleviation, and, with its positive health implication, could be a seen as an example for the Canadian government.
Engaging with the Canadian Senate Standing Committee on Social Affairs, Science, and Technology may be one pathway to improving health outcomes || (Source: Flickr // Jonathan Nightingale)
The link between poverty and bad health is grounded in decades-long academic research. Poverty and health may even form a vicious cycle, as the late Laval sociologist André Billette conceptualized it or as Collins and her colleagues traced by way of food insecurity. Raphael believed that Canada’s choice of political system was implicated in the determination of health. There are many potential economic, political, and legislative solutions. For example, activists can approach governmental committees, such as the Canadian Senate Standing Committee on Social Affairs, Science, and Technology; the Quebec National Assembly’s Committee on Health and Social Services, or the Ontario Ministry of Children, Community, and Social Services. They can advocate for research into fiscal policies (e.g. Should the government provide more generous federal and provincial social programs? How?) and political matters (e.g. What is the best way to influence anti-poverty policies? Is the liberal welfare state good for public health?). Ultimately, it is important that anti-poverty advocates continue their work, in order to ensure that all Canadians can achieve equitable health outcomes.
Gary Lai holds an MEcon in Economics from the University of Hong Kong, where he has published a paper on Hong Kong’s public health spending. He also holds a B.A. in Economics from the University of Southern California. In between, he attended UBC’s Allard School of Law and Columbia University, where he studied premedical sciences.
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